Cervicitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Several factors shouldLink title

• Treatment with antibiotics for C. trachomatis should be provided for those women at increased risk for this common STD (e.g., those aged ≤25 years, those with new or multiple sex partners, and those who engage in unprotected sex), especially if follow-up cannot be ensured and if a relatively insensitive diagnostic test is used in place of NAAT.

• Concurrent therapy for N. gonorrhoeae is indicated if the prevalence of this infection is >5% (those in younger age groups and those living in certain facilities).

• Trichomoniasis and BV should also be treated if detected. For women in whom any component of (or all) presumptive therapy is deferred, the results of sensitive tests for C. trachomatis and N. gonorrhoeae (e.g., NAATs) should determine the need for treatment subsequent to the initial evaluation.

• Antibiotics are used to treat bacterial infections, such as chlamydia, gonorrhea, and others. Drugs called antivirals may be used to treat herpes infections. Hormonal therapy (with estrogen or progesterone) may be used in women who have reached menopause (postmenopausal). When these treatments have not worked or when cervicitis has been present for a long time, treatment may include cryosurgery (freezing), electrocauterization, or laser therapy.

Nongonococcal Cervicitis Treatment

Nongonococcal Cervicitis Treatment Preferred Regimen ▸ Doxycycline 100 mg bid po x 7 days OR ▸Azithromycin 1 gm po as single dose Pregnancy ▸ Erythromycin 500 mg po qid x 7 days OR ▸Amoxicillin 500 mg po tid x 7 days Alternative Regimen ▸ Erythromycin 500 mg qid po x 7 days OR ▸Ofloxacin 300 mg q12h po x 7 days OR ▸Levofloxacin 500 mg q24h x 7 days Pregnancy ▸ Azithromycin 1 gm po single dose

Gonococcal Cervicitis Treatment

Gonococcal Cervicitis Treatment Preferred Regimen‡ ▸ Ceftriaxone 250 mg IM x 1 dose PLUS ▸ Azithromycin 1 gm PO x 1 dose for 7 days OR ▸ Doxycycline 100 mg po q12h for 7 days Alternative Regimen ▸ Azithromycin 2 gm po x 1 dose OR Cephalosporins single dose ▸ Ceftizoxime 500 mg IM OR ▸ Cefotaxime 500 mg IM OR ▸Cefoxitin 2 gm IM + Probenecid 1 gm po OR ▸ Cefixime 400 mg po¶ PLUS ▸ Azithromycin 1 gm PO x 1 doseORDoxycycline 100 mg po q12h x 7 days OR ▸ SpectinomycinNUS 2 gm IM x 1 dose Failure of treatment† ▸ Ceftriaxone 500 mg IM x 1 dose PLUS ▸ Azithromycin 2 gm po x 1dose

‡Use combination therapy even if NAAT test is negative for Chlamydiae.
†Treat sex partner, repeat NAAT test after 1 week of cure.
¶If IM cephalisporins are not available.

Proper perineal hygiene should be stressed. This includes avoiding use of vaginal deodarant sprays and proper wiping after urination and bowel movements. Intercourse should be avoided until symptoms subside.

Recurrent and Persistent Cervicitis=

Women with persistent cervicitis should be reevaluated for possible reexposure to an STD. If relapse and/or reinfection with a specific STD has been excluded, BV is not present, and sex partners have been evaluated and treated, management options for persistent cervicitis are undefined; in addition, the utility of repeated or prolonged administration of antibiotic therapy for persistent symptomatic cervicitis remains unknown. Women who receive such therapy should return after treatment so that a determination can be made regarding whether cervicitis has resolved. Research is needed on the etiology of persistent cervicitis including the potential role ofM. genitalium (266). In women with persistent symptoms that are clearly attributable to cervicitis, referral to a gynecologic specialist can be considered.

Follow-Up

Follow-up should be conducted as recommended for the infections for which a woman is treated. If symptoms persist, women should be instructed to return for re-evaluation because women with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months after treatment. Therefore, repeat testing of all women with chlamydia or gonorrhea is recommended 3-6 months after treatment, regardless of whether their sex partners were treated (267).

Management of Sex Partners

Management of sex partners of women treated for cervicitis should be appropriate for the identified or suspected STD. Partners should be notified and examined if chlamydia, gonorrhea, or trichomoniasis was identified or suspected in the index patient; these partners should then be treated for the STDs for which the index patient received treatment. To avoid reinfection, patients and their sex partners should abstain from sexual intercourse until therapy is completed (i.e., 7 days after a single-dose regimen or after completion of a 7-day regimen). Expedited partner treatment and patient referral (see Partner Management) are alternative approaches to treating male partners of women that have chlamydia or gonococcal infections (68,69,71).

Special Considerations

HIV Infection

Patients who have cervicitis and also are infected with HIV should receive the same treatment regimen as those who are HIV negative. Treatment of cervicitis in HIV-infected women is vital because cervicitis increases cervical HIV shedding. Treatment of cervicitis in HIV-infected women reduces HIV shedding from the cervix and might reduce HIV transmission to susceptible sex partners (268–270).